Healthcare Provider Details

I. General information

NPI: 1235211798
Provider Name (Legal Business Name): EDMOND X BERGERON III M.P.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 10/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

806 JEFFERSON TER
NEW IBERIA LA
70560-5727
US

IV. Provider business mailing address

806 JEFFERSON TER
NEW IBERIA LA
70560-5727
US

V. Phone/Fax

Practice location:
  • Phone: 337-365-4945
  • Fax:
Mailing address:
  • Phone: 337-365-4945
  • Fax: 337-376-6860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number606MP
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number606MP
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: